DESCRIPTION
Laboratory testing may be performed for the purpose of diagnosing an underlying cause of erectile dysfunction.
POLICY
Based on individual consideration, the following diagnostic lab tests for the diagnosis of erectile dysfunction are considered medically necessary:
Liver hepatic function panel
Lipid profile
Thyroid function study
Urine analysis
Creatinine
Glucose level
Prostate specific antigen (PSA)
Complete blood count
Serum testosterone hormone level (free or total); to assess pituitary function when the serum testosterone level is low:
Gonadotropin follicle stimulating hormone
Gonadotropin luteinizing
Serum prolactin
The following diagnostic lab tests for the diagnosis of erectile dysfunction are considered not medically necessary:
Iron binding capacity
Phosphatase, acid: Prostatic
Duplicate diagnostic lab tests for the diagnosis of erectile dysfunction is considered not medically necessary.
See also: Prostate Specific Antigen (PSA)
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
A comprehensive physical examination, including a medical and sexual history and psychosocial evaluation, should be performed prior to diagnostic lab work being ordered.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2002). Erectile dysfunction. (2.01.25). Retrieved October 1, 2008 from BlueWeb.
National Institutes of Health (1992, December 7-9). Consensus Statements: 91. Impotence. Retrieved August 6, 2001 from http://odp.od.nih.gov/consensus/cons/091/091_statement.htm.
Rosen, R., Goldstein, I., Heiman, j., Korenman, S., Lakin, M., Lue, T., et al. (1999). Position paper: The process of care model for evaluation and treatment of erectile dysfunction. International Journal of Impotence Research, 11, 59-74.
ORIGINAL EFFECTIVE DATE: 4/27/1998
MOST RECENT REVIEW DATE: 11/13/2008
ID_BA
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.